Physicians should strongly consider evaluating cirrhosis patients specifically for hepatic encephalopathy, because this neurologic disorder can be difficult to detect but can have a substantial impact on driving ability, Dr. Stanley Martin Cohen and his colleagues reported in the February issue of Clinical Gastroenterology and Hepatology.
In addition, physicians are potentially liable for any injury that may stem from this medical impairment, the authors wrote (Clin. Gastroenterol. Hepatol. 2011 February [doi:10.1016/j.cgh.2010.08.002]).
In patients with advanced liver disease, hepatic encephalopathy (HE) is a spectrum of neuropsychiatric abnormalities, from overt mental and neurologic symptoms to occult impairment. Minimal HE can be overlooked on standard neurologic assessments, and "diagnosis is only possible by using specialized psychometric and neurophysiological measures," the researchers said.
In one study, only 28% of hepatologists responding to a poll said they tested most of their cirrhotic patients for minimal HE, even though it is estimated to occur in up to 80% of cirrhosis patients.
Many studies have demonstrated that patients with minimal HE have more motor vehicle accidents and traffic violations than do people without the disorder. Between 45% and 61% of patients with minimal HE in various studies have been judged unfit to drive when tested, said Dr. Cohen of Loyola University, Maywood, Ill., and his associates.
They investigated each state’s laws and requirements for reporting of potentially impaired drivers and found that no states specifically addressed HE or impairment related to advanced liver disease. Moreover, the definition of "medically impaired" varied substantially from state to state.
Only six states – California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania – had laws requiring physicians to report medically impaired drivers to the motor vehicle department. All six provided physicians with legal immunity in such cases, so that they could not be charged with violating the patient’s right to privacy for making such reports.
Another 35 states (70%) had statutes allowing but not requiring physicians to report medically impaired drivers, but only 24 of these provided physicians with legal immunity for doing so.
The remaining nine states – Alaska, Hawaii, Massachusetts, Mississippi, South Carolina, Tennessee, Vermont, Washington, and Wyoming – had no statutes addressing physician reporting of medically impaired drivers, and only one of these nine provided physicians with legal immunity.
The investigators also reviewed several legal databases, legal journals, and case records from federal and state courts, and found that so far, there have been no completed lawsuits in which a physician was cited for failure to warn patients not to drive or for failure to diagnose HE that subsequently caused a motor vehicle accident. There also have been no completed lawsuits to date against patients with HE for causing an accident while operating a motor vehicle.
However, this review encompassed only cases that were adjudicated in the courts; information on lawsuits settled out of court was not available, they noted.
"We believe that it would be prudent for society to consider a recommendation to restrict the driving privileges of patients with any degree of HE," Dr. Cohen and his colleagues said.
The physician’s role would be to identify and report such patients to the proper governmental agency, which would then conduct a driving evaluation. "Until society and the legislature write the definitive laws determining individual rights versus public safety, the onus of responsibility for identifying potentially hazardous drivers (and the associated liability) might still lie with the physician," the authors noted.
The researchers cautioned that even in the few places where such laws already exist, they are difficult to enforce, so reporting is "suboptimal." One study showed that 86% of physicians in California, where such reporting is mandatory, "never" or "occasionally" did so. Only 12% of the physicians in that survey had actually read the laws.
The authors disclosed no conflicts of interest.